Systematic performance status assessment by primary care providers in patients with advanced cancer and its impact on referral to palliative care and cost in a value-based practice.
Authors: Roberto Enrique Ochoa, Say Salomon, Alexandra King, Peter Joel Hosein, Ernesto Prats Leon, Candace Gilbert, Daniel Guerra, Christopher James Chen, Scott Tromanhauser, James Chen
Journal: Journal of Clinical Oncology (2022)

6595 Background: Value Based (VB) Care model has been growing in the primary care (PrC) Medicare population, its role in oncology and integration with VB PrC has not been well defined. Key initiatives in VB include reducing hospitalizations by multidisciplinary management of chronic conditions. Earlier Palliative Care (PaC) has shown to favorably impact outcomes. Eastern Cooperative Oncology Group Performance Status (ECOG-PS) is a validated tool used for decision making. Poor PS is associated with worse outcomes and futile end of life care; Guidelines recommend using ECOG-PS to decide on involvement of PaC in patients (pts) with metastatic cancer (mCa). ECOG-PS is subject to significant variability among oncologists and rarely used by PrC providers (PCPs). We created a standardized system for ECOG-PS documentation and monitoring by PCPs in a VB model in a large Medicare Advantage (MA) population with the goal of increasing earlier PaC referrals. Methods: Pts with mCa managed by PCPs in a multi-state MA practice were identified via EMR from February 2021 to September 2021. At every visit, an automated alert asked PCPs to determine pts’ ECOG-PS and for those ≥ 2, recommendation to refer to PaC. PCPs were trained on use of the tool and were given a script to discuss with pts the role of PaC. Hospital admissions as well as total cost of care was measured in pts comanaged by PCP’s &amp; PaC versus those managed by PCPs &amp;Oncology without PaC. Statistical analysis between the groups was done using Pearson's Chi-squared test with Yates' continuity correction. Results: An ECOG-PS was measured in a total of 565 pts with mCa during the study period. Median age was 73 years, 40% were ≥75 yrs. 55% were female. Breast, Prostate, Lung, Colorectal and Gyn ca accounted for 75% cases. ECOG was documented in 97% of patients; 250 (44%) had ECOG ≥ 2, 124 (22%) had ECOG ≥ 3. Of those PaC referral was done by the PCP in 70%, in total 69 patients were comanaged by PC vs 181 who did not. Pts that had PaC involvement were 43% less likely (RR 0.57 [95%CI 0.33,0.98 p = 0.043]) to be admitted compared to patients without PC. Pts without PaC that were admitted had 238% higher admission days per 1,000 pts compared to pts comanaged by PaC. Total medical costs of pts comanaged by PaC was 86% lower after PaC involvement $18,541 3-months prior vs $2,742 3-months after PaC involvemen, driven by lower part A and part B costs (p=0.001) Conclusions: ECOG PS monitoring of pts with mCa by PCPs was very successful, easy to perform and implement in a PrC. Poor PS is common in this medicare advantage population. PaC involvement in pts with poor ECOG-PS was associated with lower admission rates at the end of life, and significantly lower total medical costs. [Table: see text]